Design of patient tracking tools may have unintended consequences

BUFFALO, N.Y. -- Proper design of computational tools is critical if they are to be used with success in patient-care settings, particularly in hospital emergency rooms, a field study conducted by researchers at the University at Buffalo and other institutions recently revealed.

Nationwide, electronic patient tracking technologies are replacing traditional, dry-erase patient status boards, according to the UB researchers, who conducted the study with colleagues at the University of Rochester and the University of Florida, Jacksonville.

The results were presented last month by the UB researchers at the annual meeting of the Human Factors and Ergonomics Society.

The researchers studied how new electronic patient-status boards were functioning in the emergency departments of two busy, university-affiliated hospitals.

Overall, the UB researchers found that the computational tracking systems tended to affect how health-care providers communicate information and track activities regarding patient care, which can cause providers to change the way they work.

The results provide an important case study of what can happen when new technologies are developed without sufficient understanding by designers of the nature of the work in which they will be used, according to Ann Bisantz, Ph.D., associate professor of industrial and systems engineering in the UB School of Engineering and Applied Sciences, and a co-investigator on the study.

"Research in human factors, the study of the interactions between humans and technology, has shown that in complex workplaces where safety is critical, such mismatches between the way practitioners work and the technologies that are supposed to support them can have unintended consequences, including inefficiencies and workarounds, where the technology demands that people change their work method," said Bisantz.

She noted that there were surface similarities between the manual patient-status whiteboards that emergency departments have traditionally used and the electronic ones that were installed.

But in observations, focus groups and interviews with nurses, physicians, secretaries, IT specialists and administrators, the UB researchers learned that the computerized systems were not designed to match all of the underlying functionality of the manual boards.

According to Bisantz, manual whiteboards perform a critical, central function for emergency departments, providing not just patient names and demographic information, but also a means for health-care workers to share information on patient complaints, vital signs, lab tests, consultations, dietary and allergy alerts, and notices about patient rooms that need to be cleaned.

The results revealed that the innate flexibility of the manual whiteboard allowed health-care providers and other emergency department staff to use it to communicate with one another.

"The manual whiteboard allows flexibility in tracking patients," Bisantz said. "For example, maybe the first time the provider sees a patient, she initials the name on the whiteboard, then the next time she circles the initials, then when the patient is discharged, she might put an "x" in the circle, signals that are a means of communicating with her colleagues in the ER.

"With a computerized system, providers have to find an available computer terminal and log-in," she said, noting: "The providers can't just walk up to the whiteboard and make a notation."

In some cases, providers noted that computer systems hid some of the information; if only three comments could be viewed per screen, they had to click to get to another screen, requiring them to search for information that might demand immediate attention.

The study also found that there were fewer visual cues with the computational system. Some providers noted that they used to be able to get a sense of the status of the emergency department just by walking through the room and visually checking the manual whiteboard.

"Without that public display, providers have to sit down at the computer and check it, which can add time or reduce awareness," said Bisantz.

Future modifications to computational tools for patient tracking may serve to make such systems better correspond to user needs, Bisantz said, as long as such modifications are based on user data, such as the information in this study.

"If you don't understand the underlying structure of the work that is being done in a particular setting, then you cannot design the technology that will best support it," Bisantz said.

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Priyadarshini R. Pennathur, a doctoral candidate in the UB Department of Industrial and Systems Engineering, was a co-author on the research. The work was performed under a grant from the Emergency Medicine Foundation awarded to Robert L. Wears, M.D., University of Florida, Jacksonville, a co-author on the work. Other co-authors were Shawna J. Perry, M.D., University of Florida, Jacksonville; Rollin J. Fairbanks, M.D., and Frank Zwemer, M.D., both of the University of Rochester.

The UB researchers have now received funding from the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services to develop simulations of proposed electronic patient tracking systems in order to better evaluate and match them to the needs of hospital emergency departments. In addition to Bisantz, co-investigators on that grant are Li Lin, Ph.D., UB professor of industrial and systems engineering; Jennifer Brown, M.D., clinical assistant professor of emergency medicine in the UB School of Medicine and Biomedical Sciences and attending physician, Erie County Medical Center, as well as collaborators at the University of Rochester and the University of Florida.
The University at Buffalo is a premier research-intensive public university, the largest and most comprehensive campus in the State University of New York. UB's more than 28,000 students pursue their academic interests through more than 300 undergraduate, graduate and professional degree programs. Founded in 1846, the University at Buffalo is a member of the Association of American Universities.

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